RLE Nursing Skill No. 2 3 Body Mech Restraints

,
Republic of the Philippines

UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar
Web: http://uep.edu.ph Email: uepnsofficial@gmail.com
COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

BS NURSING
NCM 103:
FUNDAMENTALS OF NURSING PRACTICE
RELATED LEARNING EXPERIENCE
NURSING SKILLS NO. 2 SAFETY & SECURITY
Prepared by:
NEMIA G. FLORANO, RN, MMEM

Professor
RLE Nursing Skills # 2: Safety and Security
 Body Mechanics and Positioning
PRINCIPLES OF BODY MECHANICS
a. The wider the base of support, the greater the stability of the nurse
b. The lower the center of gravity, the greater the stability of the nurse
c. The equilibrium of an object is maintained as long as the line of gravity passes through the
base of support
d. Facing the direction of movement prevents abnormal twisting of the spine
e. Dividing balance activity between arms and legs reduces the risk of back injury
f. Leverage, rolling, turning, or pivoting requires less work than lifting
g. When friction is reduced in between arms and legs reduces the risk of back injury
h. When friction is reduced between the object to be moved and the surface on which it is
moved, less force is required to move it
i. Reducing the force of work reduces the risk of injury
j. Maintaining good body mechanics reduces fatigue of the muscle groups
k. Alternating periods of rest and activity helps to reduce fatigue
Devices Used for Proper Positioning

Devices Uses & Description
Trochanter Rolls Prevent external rotation of legs when clients are in supine position.
The roll is place under the buttocks and then rolled away from the
client until the high is in neutral position or an inward position with
the patella facing upward.
Maintain the thumb slightly adducted and in opposition to the fingers;
Hand Rolls
they maintain fingers in a lightly flexed position
Individually molded for the client to maintain proper alignment of the
Hand-wrist splint thumb in slight adduction and the wrist in slight dorsiflexion. These
splints should be used only for the client for whom they were made
Descends from a securely fastened overhead bar attached to the bed
Trapeze bar frame. Allows the client to use upper extremities to raise the trunk off
the bed, to assist in transfer from bed to wheelchair, or to perform
upper arm strengthening exercises.
Side rails Are bars positioned along the sides of the length of the bed
Are plywood boards placed under the entire surface of the mattress.
They are useful for increasing back support and alignment, especially
with a soft mattress
Or abductor pillow is a triangular-shaped pillow made of heavy foam.
It is used to maintain legs in abduction following total hip
replacement surgery
Positioning Techniques
 In general, clients should be repositioned as needed and at least
– -every 2 hours if they are in bed
– -every 20 to 30 minutes if they are sitting in a chair
Kinds of Positioning Techniques
 Fowler’s (45-60% head elevation)
-The head of the client’s bed is elevated, and the client’s knees are slightly elevated to avoid
pressure on the popliteal vessels. This position allows lung expansion. It also decreases risk of
aspiration.
 Supine (rests on the back)
-The supine position is when the client rest on the back. The risk of aspiration is greater with this
position; thus, supine position should be avoided when client is confused, agitated, experiencing a
decreased level of consciousness, or is at risk of aspiration.
 Prone (face-down position)
-
 Lateral (side-lying)
-In side-lying position, the client is supported on the right or left side with the opposite arm, thigh
and knee flexed and resting on the bed. The upper leg is flexed at the hip and knee positioned on
a small pillow. Clients who are obese or older may not be able to tolerate this position for any
length of time.
 Sim’s (semi-prone)
-The client is semi-prone on the right or left with the opposite arm, thigh and knees flexed and
resting on the bed. The sim’s position differs from the side-lying position in the distribution of
the client’s weight. In this position, the client’s weight is placed on the anterior ilium. Humerus,
and clavicle.
Principles & Considerations to Remember

 Improper positioning can cause unnecessary harm to clients, such as
– skin breakdown and joint contractures, especially if they have certain pre-existing
conditions such as
 peripheral vascular disease or diabetes
 Positions that compromise peripheral blood flow
– may damage nerves as well
 Every time your client is repositioned, make certain to check: 1.) total body alignment; 2.)
placement of extremities; 3.) Skin breakdown; and 4.) Joint contractures.
RLE Nursing Skills # 3: Applying Restraints
Republic of the Philippines

UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar
Web: http://uep.edu.ph Email: uepnsofficial@gmail.com
COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES
BS NURSING
NCM 103: FUNDAMENTALS OF NURSING PRACTICE
PERFORMANCE EVALUATION CHECKLIST

APPLYING RESTRAINTS
Name of Student: ______________________________________________________________________
Year/Clinical Group: _______________ Semester/Term___1 st Semester ___2nd Semester ____ Summer
Inclusive Dates of Clinical Rotation: ________________________________________________________
3 2 1
Able to Able to Not able
Preparation perform perform to
Remarks
with perform
assistance
1. Assess:
 The behavior indicating
the possible need for
restraint
 Underlying caused for
assessed behavior
 What other protective
measures may be
implemented before
applying restraint
 Status of skin to which
restraint is to be applied
 Circulatory status distal to
restraint of extremities
 Effectiveness of other
available safety
precautions
2. Review institutional policy for

restraints
3. Assemble equipment and

supplies:
a. Appropriate type and size
of restraint
PROCEDURE
1.Explain to the client what are you

going to do, why it is necessary, and
how they can cooperate.
2. Wash hands and observe appropriate

infection control.
3.Provide for client privacy, if indicated.
4. Apply selected restraint.
Belt Restraint (Safety Belt)
1.Determine that the safety belt is in

good order. If a Velcro safety belt is to
be used, make sure that both pieces of
Velcro are intact.
2. If the belt has a long portion and a

shorter portion, place the long portion of
the belt behind (under) the bedridden
client and secure it to the movable part
of the bed frame. Place the shorter
portion of the belt around the client’s
waist, over the gown. There should be
a finger’s width between the belt and the
client.
Or;
Attach the belt around the client’s waist
and fasten it at the back of the chair.
Or;
If the belt is attached to a stretcher,
secure the belt firmly over the client’s
hips or abdomen.
Jacket Restraint
1. Place vest on client, with opening
at the front or the back,
depending on the type.
2. Pull the tie on the end of the vest

flap across the chest, and place it
through the slit in the opposite
side of the chest.
3. Repeat for the other tie. Use a

half-bow knot to secure each tie
around the movable bed frame,
or behind the chair to a chair leg.
4. Fasten the ties together behind

the chair using a square (reef)
knot.
5. Ensure that the client is

positioned appropriately to
enable maximum chest
expansion for breathing.
Mitt Restraint
1. Apply the commercial thumbless

mitt to the hand to be restrained.
Make sure the fingers can be
slightly flexed and are not caught
under the hand.
2. Follow the manufacturer’s

directions for securing the mitt.
3. If a mitt is to be worn for several

days, remove it at least every 2-4
hours. Wash and exercise the
client’s hand, then re-apply the
mitt. Check agency practices
about recommended intervals for
removal.
4. Assess the client’s circulation to

the hands shortly after the mitt is
applied and at regular intervals.
Wrist and Ankle Restraint
1. Pad bony prominences on the

wrist or ankle, if needed to
prevent skin breakdown.
2. Apply the padded portion of the

restraint around the ankle or
wrist.
3. Pull the tie of the restraint

through the slit on the wrist
portion or through the buckle.
4. Using a half bow or square knots,

as appropriate, attach the other
end of the restraint to the
movable portion of the bed frame.
5. Document:
a. Behavior(s). indicating the need
for the restraint.
b. All other interventions
implemented in the attempt to
avoid the use of the restraints
and their outcomes.
c. The time the physician was
notified of the need for restraint.
Also record:
d. The type pf restraint applied, the
time it was applied, and the goal
for its application,
e. The client’s response to the
restraint.
f. The times that the restraints were
removed and skin care given.
g. Any other assessments and
interventions.
h. Explanations given to the client
and significant others.
6. Adjust the plan of care as

required.
Remarks:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Conforme:
_________________________________ ________________________________
Printed Name & Signature of Student Printed Name & Signature of Evaluator/
________________________________________ Clinical Instructor
Date & Time of Evaluation
Ngf/2021

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,

Republic of the Philippines

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

NURSING SKILLS NO. 2 SAFETY & SECURITY

NEMIA G. FLORANO, RN, MMEM

Devices Used for Proper Positioning

Principles & Considerations to Remember

RLE Nursing Skills # 3: Applying Restraints

Republic of the Philippines

NCM 103: FUNDAMENTALS OF NURSING PRACTICE

PERFORMANCE EVALUATION CHECKLIST

2. Review institutional policy for

3. Assemble equipment and

1.Explain to the client what are you

2. Wash hands and observe appropriate

3.Provide for client privacy, if indicated.

4. Apply selected restraint.

Belt Restraint (Safety Belt)

1.Determine that the safety belt is in

2. If the belt has a long portion and a

2. Pull the tie on the end of the vest

3. Repeat for the other tie. Use a

4. Fasten the ties together behind

5. Ensure that the client is

1. Apply the commercial thumbless

2. Follow the manufacturer’s

3. If a mitt is to be worn for several

4. Assess the client’s circulation to

1. Pad bony prominences on the

2. Apply the padded portion of the

3. Pull the tie of the restraint

4. Using a half bow or square knots,

6. Adjust the plan of care as

________________________________________ Clinical Instructor

Date & Time of Evaluation

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